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Town of Barnstable
b
g pP. Shed
7 PostThis Card So That it is Visible From;the Street-A roved-Plans Must be Retained-on 1ob.and this Card Must-be Kept
srgri a •
Posted Until Final;lns inspection Has Been Made..
p Re istration
Where a Certificate ofOccupancy is Required,such Building shall Not be Occupied until a Final Inspection has been�made. g
Registration Number: 13-204062 Applicant Name: TERWILLIGER,JEFFREY M & EILEEN H Ap
provals
Date Issued: 04/23/2020 Current Use: Structure
Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 10/23/2020 Foundation:
Location: 57 HALYARD WAY,CENTERVILLE Map/Lot: 194-066 Zoning District: RC Sheathing:
Owner on Record: TERWILLIGER,JEFFREY M & EILEEN H Contractor Name:°` Framing: 1
Address: 57 HALYARD WAY Contractor License: N 2
CENTERVILLE, MA 02632 Est. Project Cost: $0.00 Chimney:
Y
Description: shed 8x15 Permit Fee: $35.00
Insulation:
Fee Paid-;" $35.00
Project Review Req: ( `
Date. 4/23/2020 Final: _
� µ
Plumbing/Gas
I Rough Plumbing:
Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.
All work authorized by this permit shall conform to the approved application and the°approved construction.documents for.which this permit has been granted. Rough Gas:
All construction,alterations and changes of use of any building and structures shall be.in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas:
work until the completion of the same. '
`` rF Electrical
The Certificate of Occupancy will not be'issued until all applicable signatures`by-the Building and Fire Officials are provided on this permit.
Minimum of Five Call Inspections Required for All Construction Work:l f Service:
1.Foundation or Footing
2.Sheathing Inspection a Rough:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: .
5.Prior to Covering Structural Members(Frame Inspection)
Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy
Low Voltage Final
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Health
Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
Building plans are to be available on site Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
Town of Barnstable
Building,Department Services - U � flve �.
Brian Florence,CBO
4 •
r BAs MBM * Building.Commissioner APR 9
NAsa
1639. �� 200 Main Street, Hyannis,MA 02601 TO
www.town.barnstable.ma.us ��..�F gA pAl' T.
t,
Office: 508-862-4038 Fax: 508-790-6230
PERMIT# C/" FEE: $35.00
SHED REGISTRATION
RESIDENTIAL ONLY
200 square feet or less
Location of shed(address) - Village r
Property owner's name Telephone number
6(0
Size of Shed Map/Parcel#
r E-Mail c�TgCLJIV-1 -S���i►���- A'�T
/SignaW Date
Hyannis Main Street.Waterfront Historic District? (Vo
Old King's Highway Historic District Commission jurisdiction?
You must file with Old King's Highway
Conservation Commission(signature is required)
Sign off hours for Conservation 8:00-9:30&3:30-4:30
PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE
ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION
FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS.
THIS FORM MUST BE ACCOMPANIED BY A
PLOT PLAN
Q-forms-shedreg
REV:08/6/17
MAP 194 /
PCL 57 s:
MAP 194 —
PCL 59 \ _�
N
/
,EN�
LOT 29
20,764t S.F. c+ /
(0.48t AC.)
MAP 194
PCL 67
MAP 194 No /
PCL 65 +► /
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ZVA) 6�' •
z lb• k
I�� vi R '�
i I10' 10 I S R 1094 64'
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MORTGAGE INSPECTION PLAN xTHIIRPO ES- ONLY INTENDED. TH IS OR BANK INSTRU AGE
LOCUS 57 HALYARD "AY ENT
SURVEY AND IS NOT TO BE USED FOR FENCING,
CONSTRUCTION, DEED DESCRIPTIONS, RECORDING,
CENTERVILLE, MA BUILDING:OFFSETS OR PROPERTY LINE DEFINITION.
REF ': PLAN'BOOK 379 PAGE 70
PLAN PREPARED FOR �o JOHN GN
Z:
CAPE COD COOPERATIVE .�` MK DEMAREST,.JR.
SCALE 1"=40' DATE 6/16/2011 q N0.3
OWNER OF RECORD: KEITH J. & ANN MARIE ALLAIN
THE DWELLING AS SHOWN ,COMPLIED WITH THE BARNSTABLE DATE REG ND SURV OR
ZONING BYLAW BUILDING SETBACK REQUIREMENTS WHEN CONSTRUCTED.
OR EXEMPT FROM VIOLATION UNDER M.G.L. TITLE` VII, CHAPTER 40A,
SECTION 7. s JOHN Z. DEMAREST JR.,P.L.S.
THERE ARE NO VISIBLE EASEMENTS OR ENCROACHMENTS OTHER THAN PROFESSIONAL LAND SURVEYOR
UNDERGROUND SITE UTILITIES OR AS NOTED ON THE PLAN. 338 MAYFAIR ROAD,
THE DWELLING IS NOT LOCATED IN AN ESTABLISHED FLOOD HAZARD SOUTH DENNIS, MA7�02660
AREA AS DEFINED ON F.E.M.A COMMUNITY 'PANEL`# 250001 0015 C (508) 398-6717
FILE=1 10008.OWG
Town of Barnstable _—`�
` p I
' ena.�•srua.e.
Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must"be Ke t Shed
"'"� ,•bg Posted Until Final Inspection Has Been Made. •
Registration
i0'Fcru�'' Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made.
Registration Number: B-20-1062 Applicant Name: TERWILLIGER,JEFFREY M & EILEEN H Approvals
Date Issued: 04/23/2020 Current Use: Structure
Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 10/23/2020 Foundation:
Location: 57 HALYARD WAY,CENTERVILLE Map/Lot: 194-066 Zoning District: . RC Sheathing:
Owner on Record: TERWILLIGER,JEFFREY M& EILEEN H Contractor Name: Framing: 1
Address: 57 HALYARD WAY Contractor License: 2
CENTERVILLE, MA 02632 Est. Project Cost: $0.00 Chimney:
Description: shed 8x15 Permit Fee: $35.00
Insulation:
Fee Paid: $35.00
Project Review Req:
Date: 4/23/2020 Final:
Plumbing/Gas
•�"' Rough Plumbing:
Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within,six months aftervissuance:"
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas:'
All construction,alterations and changes of use of any building and st;uctures shall be in compliance with the local zoning by-;laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas:
work until the completion of the same.
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Electrical
Minimum of Five Call Inspections Required for All Construction Work: Service:
1.Foundation or Footing
2.Sheathing Inspection Rough:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Rough:
7.Final Inspection before Occupancy
Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until the Inspector has approved the various stages of construction..
Final:.
"Person cting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
� Building plans are to be available on site Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
• J
n+�
Town of Barnstable
wp,pix ,. n g
nsta
. 1
s,.axsrws�e Poo „ - eet^ Approved P1anc Must be Retained on Job end this card,Must be'Kept +v.
t This Card So That it is Visible From the$tr
Mill 9. �u:s. .7I' ",h"e"A,"' .:� ,..' o..,._ qy jg N.' ��^.4'.,.,r �t cc•,' q :a.:. § `'z ^r}.S3w :rid _
Hosted Untd Final Inspection Has Been Made. a _ LL _ ti ?
.a., . ' ,.haA .LAMA 4`Wc. ,t.CZ
•
t p.. _ ...
Where a Certificate of Occupancy is-Required,such cBuild�ng,shaq Not be Occupied until a Final Inspection has:been;;made ;'
Init '.
Permit NO. B-18-2714 Applicant Name: Henry Cassidy Approvals
Date Issued: 08/21/2018 Current Use: Structure
Permit Type: Building-Insulation-Residential Expiration Date: 02/21/2019 Foundation:
Location: 57 HALYARD WAY,CENTERVILLE Map/Lot: 194-066 Zoning District: RC Sheathing:
Owner on Record: TERWILLIGER,JEFFREY M&EILEEN H t Contractor Name: HENRY E CASSIDY Framing: 1
Address: 57 HALYARD WAY ; Contractor License CS400988 2
CENTERVILLE, MA 02632 � �- "�
` Est Projdct Cost: $1,000.00 Chimney:
Description: Install 12" layer unfaced fbg batts to 28 sq ft damming purposes,6" Permit,F e: $85.00
la er R 22 cellulose to 684 s ft to o en attics ace. ' ° Insulation:
4 Y P P
-. _. Fee Paid:: $85.00
Project Review Req: t Date ° 8/21/2018 Final:
Plumbing/Gas
b
Rough Plumbing:
A
Building Official Final Plumbing:
Y
Rough Gas:
This permit shall be deemed abandoned and invalid unless the work authorized by"ihis permit is commenced within six months after:issuance.
All work authorized by this permit shall conform to the approved application:and the"approved construction documents for wh cli this permit has been granted. Final Gas:
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws a codes. .
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. - r --y Electrical
Service:
The Certificate of Occupancy will not be issued until all applicable signatures 6ythe Building and Fire Officials are provided'on this permit.
Minimum of Five Call Inspections Required for All Construction Work ,. Rough:
1.Foundation or Footing
2.Sheathing Inspection Final:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Final:
7.Final Inspection before Occupancy Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. �✓ Final:
Work shall not proceed until the Inspector has approved the various stages of construction.
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (asset forth in MGL c.142A). Fire Department
Final:
Building plans are to be available on site
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
t
Town of Barnstable Building
wnNsrwo Post This Card So That it is Visible.From-the Street, Approved Plans Must b_e Retained ow o and this Card Must be Kept .
' Posted Until Final Inspection Has Been Made s.. Permit
Where a Certificate of Occu anc is Re. uired,;such Buildin shall Not be Occu ied until a Final Ins ection`has been madeI I
Permit No. B-18-217 Applicant Name: DAVID A. CARROLL Approvals
Date Issued: 01/24/2018 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 07/24/2018 Foundation:
Location: 57 HALYARD WAY,CENTERVILLE Map/Lot: 194-066 Zoning District: RC Sheathing:
Owner on Record: TERWILLIGER,JEFFREY M&EILEEN H Contractor Name h DAVID A.CARROLL Framing: 1
Address: 57 HALYARD WAY Contractor License 123111 2
CENTERVILLE, MA 02632 F _ Est Project Cost: $3,800.00 Chimney:
Description: (reroof)Stripping old shingles -Permit Fee: $35.00
Insulation:
Project Review Req: fee Pal $35.00
ti Date 1/24/2018 Final:
Plumbing/Gas
F
Rough Plumbing.
Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within siz'm brit fis'af'er issuance. Rough Gas:
All work authorized by this permit shall conform to the approved application:and theapproved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in with the local zoning by laws and codes. Final Gas:
This permit shall be displayed in a location clearly visible from access street or Iroad and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. ., Electrical
The Certificate of Occupancy will not be issued until all applicable signatures 6y the Building end Fire Officials are provided on this permit. Service:
Minimum of Five Call Inspections Required for All Construction Work: V Rough:
1.Foundation or Footing
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation
Low Voltage Final:
7.Final Inspection before Occupancy
Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Fire Department
Building plans are to be available on site Final:
�, All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
�$
Town Of Barnstable *Permit#
�pU 1 T°yti Expires 6 months from issue date
Building Department Services Fee
RU,,rm.,mL : Brian Florence,CBO p�
v MAM Building Commissioner16
V
�'°tFo ►�� 200 Main Street,Hyannis,MA 02601
www.townbarnstable.ma.us
Office: 508-862-4038 j0/ FaA5,08-790-6230
, �,�
EXPRESS PERMIT APPLICATION - RESIDENTIA` �O NEW�,
T Not Valid without Red X-Press Imprint %*A
Map/parcel Number
Property Address -7 tv,4v C C6u-rr_r v 1tar_ /14
Residential Value of Work$ 3 d 1 d 6 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address T F T/� C R Lj z LL_7 6�_ 1Z
Contractor's Name c , A 4" 00, M_ Telephone Number Smg— SZi t(- 7(e-?6
Home Improvement Contractor License#(if applicable) Email: _'0 v ^ LL L Li QTda l Co K1
Construction Supervisor's License#(if applicable) CC RK Q 60 a 6 s
❑Workman's Compensation Insurance
Check one:
`Z I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
�e-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
QAWPMESTORM%building permit forms\EXPRESS.doc
08/16/17
?lie Coamrl:orrivealth o,fMassr diusetts
Deprarhment ct,f lidustrial Accidents
lure ofinvestigadem
. . 600 Washbi<gifon Street
-- Boston ?MA 02111
wrviurnasagovIdia
Mlarkers' Cumpensaf on Insurance Affidav&$adersJContractursMectr cians/Phu nbers
ATtr pEcant Information Please Print Legibly
Nam(Bnsme�z±mfi nffn&Ui9Y- I tea 1- ( r, a-U?ll-
'
City/Statel : f•cx ane STaq-7&-(
Are you an employer?Check the appropriate bor: Type of project(required}:
1.❑ I am a em to_ with 4. ❑I am a general contractor and I
P � 6_ ❑New construction
employees(full anchor part-time)* have hired the sub-contractors
2.. a sole proprietor or partner- listed on the attached slxeef 7. ❑Remodeling�11y/// sSup and fsaz�e na employees These sub-contrac-tars have 8. Q Demolition
w'oAdngr for me in arty capacif employees and have wormers' 9_ El Building addition
[NO Worloars,Comp.insurance comp.insurauc�1
5. ❑ 'fie are a corporation and its 1�0�El Electrical repairs or additions
3_❑ 1 m a fiQmeowner doing all work officers have exercised their 1L 0 Plumbingrepairs or additions.
aw
�, right of exemption per MGI.
mpsel£� camp 1.�2
_❑ICoofrepatrs
insurance rewiredl E c.152,§1(41 and we have no
employees.[No workers' 13.❑Other
comp-insurance required-] '
*tiny applicutthat ched3box P1 rsanst also SIlrnutthe secdon below sbmsing ffiek wo3cexe eompenmdonPolicy iffbM rauaa_
Hnmevamerswhosubmitdaisaffid2mrgm&czt gdv_yaredoingollwoaxand&mhireauto@econtracmrsmnstsuhmitanewaffida4itiodieabaosack
fC'on=ctoa-fimt rhwi th s brae must attached=additi�sl shea shotrmg the nme of the s¢b-con=ctmT soul state whether or matt7anse eudtieshave
emp1mlees.if the subtaatrsctmshneemployee!;&eY=Ls'pmvidetheir nrorkecs'-cmap.policynm:aber-
I am an empIayer tfeatisprav ding ivarke.rs'compensa crn insurance for mf mrpko we% Ealoiv is ffEe paFicy imd jabs ske
artforraatarrn
Insurance Company Name:
Policy 4 or Self-ins.Lic_ :� ;f ' Dxpisat onDate-
r Job Site Ahdres, ffA- 7 �-b �1/�y City/Statet :
Aftacl3 a copy ofthe workers'compensationp.olicydeclar�tion page(shawirtg the policy number and expiration date).
Failure to secure coverage as required.under Section 25A of MGL c 152 can lead to the imposition of criminal penalties of a
fine up to$1,50D 00 andt'or one-year imprison as welt as civil penalties in 1he form of a STOP WORK€RDERand a hme
of up to$250-00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations.of the DIA€oar insurance coverage s erificatia�
I d`o hiereby c ander- tepruns and talfres o"garJux?�fhatifte infar�sxcrfimrprmtirTtfdabarna is.true as:d crrrcect
SiEoature: � Date:
Phone- -T](i 76
t9&W use drily. Do not svrke in dds yea;to be camp[eted by dty artoirn arfjiciat
City or Town: PermitMicense#
Issuing Authority(circle one):
1.Board of Iffealtlt 3.Su l&ng Department 3.City]Town Clerk 4 Electrical Inspector a.Plumbing Inspector
G.Other
Contact Person: Phone#:
-- -- --- --- 6
' Town of Barnstable ,
F
Building Department Services
ASS Brian Florence,CBO
16,7 ��� Building Commissioner
°lam 200 Main Street,Hyannis,MA 02601
www.town.barnstable.maxs
1
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I Err-a v as Owner of the subject property
hereby authorize 1�t20 Gi l� 4016 f4 to act on my behalf,
in all matters relative to work authorized by this building permit application for. ,
(Addy ss of Job)
**Pool fences and alarms are the responsibility of the applicant Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Sina �f(� ner Signature of Applicant
Print Name Print Name
' t
Date -
Q:FORMS:OWNERPERMISSIONPOOLS
Rev:08/16/17
Massachusetts Department of Public Safety `-
Board of Building Regulations and Standards -
License: CSFA-060265
Construction Supervisor 1 & 2
Family
DAVID A CARROLL '
12 FEDERICK B DOUGLAS RD '
N.FALMOUTH MA 02666
Expiration:
Commis'
sioher 03108/2019
a Office of Consumer Affairs&Business Regulation
E HOME IMPROVEMENT CONTRACTOR- Registration valid for Individual use only
TYPE:.Individual before the expiration date. if found return to:
Office of Consumer Affairs and Business Regulation t
Real —n � � 10 Park Plaza-Suite 5170 ;
123111 12/09/2018 Boston,MA 02116 .+
DAVID A.CARROLL
;7
D/B/A Cape Cod`Remod WOO and Design
I DAVID CARROLL
12 Frederick B Douglas Rd l
N.Falmouth,MA 02558' Undersecretary Not valid without signature
•
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
-•a
t
p Parcel �' Application #
Health Division k'' 'r ', 3 Date Issued
Conservation Division Application Fe
Planning Dept. "' Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address ��
Village
Owner 2 R Ile,c- Address &/., Wr-4C
Telephone
Permit Request Pod�_-1,6p S�J a�` o ��e
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain _Groundwater Overlay
Project Valuatiof� c�d
� ,J G� Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ! L Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ANo On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing —new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name cl -G-S Fq�S a Telephone Number S�C`�'-�cj-�' '
Address 3_0Z Gt/A,P License #
f 4 a RY,� Home Improvement Contractor# �3
Email COY" Worker's Compensation #/, -VZ
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
~ FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
s
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
r.
ASSOCIATION PLAN NO.
.,
� 3 � MEs
OEM-
41
",�.
J < 4
THOMAS L PITTSLEY III
356 WAREHAM ST
MIDDLEBORO MA 0234 ur It
Vy�
09:102;2017
777
YA .
()#'#ice of ('un•urrtc-r-:affairs .� HrIslI1c�••.Hc� ul:rtivil
of y,
HOME IMPROVEMENT CONTRACTOR
Registration: 183533 Type:
J`= Expiration: 10/21/201 7 [ndividual z
a
-'Y-f 10MAS L. PITTSLEY Ill
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i_HOMAS PITTSLEY
356.vVA PEHAM ST
MIDDLEBORO, MA 0?:��k�
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• /ARNSPABLM
MA
SS. - Town of Barnstable
Regulatory Services '
Richard V.Scali,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
i
1. Jowi (O�(LL 162,4z-
as Owner of the subject property .
AA
hereby authorize `" 5�� to act on my behalf,
in all matters relative to work authorized by this building permit application for: '
5�7 NAoy P-rp L J,4 L-1 C%VtZuxe vA
(Address of Job) .
c io it
4Sigmnaeof OGTner Date -
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.' k'
C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Inter'iet Files\Content.0utlookUPI0IDWEXPRESS.doc
Revised 04W 15
Jeff Terwilliger -and W Synergy Home Energy Solutions
57 Hal a 5.7 DC kW Solar Array Using 20 SW-285 Modules&20 P300 SE
y y Optimizers&SE-6000A-US Inverter 356 Wareham St
Centerville MA 02632 Middleboro MA 02346
1 x#6 THWN-2/THHN-2 BLACK
1 x#6 THWN-2/THHN-2 RED
1 x#6 THWN-2/THHN-2 WHITE
1 x#10 THWN-2/THHN-2 GRN
1"EMT INDOORS M UTILITY METER
" 1 x#10 THWN-2/THHN-2 BLACK 4 WIRES
M- O
0 0 10 1 x#10 THWN-2/THHN-2 RED LST IN OUTDOOR
2 x#10 PV Rated Cable 1 x#10 THWN-2/THHN-2 WHITE o JUNCTION eox
1 x#10 Bare Copper 1 x#10 THWN-21THHN-2 GRN
DC 1"EMT INDOORSPTIMIZER + INVERTER LISTED
——— SOLAREDGE 1 MEP
1
Q I SE-6000A-US MEP J
Q 1 2 3 o a 10
7
G AC LIN LINE N
DC _ M oND
OPTIMIZER = + DC(� oA
T LOAD
A/ DC '
DC. INTEGRATED
— DISCONNECT
W 00 AC FUSED —
J SolaDeck-Pass_ — — — REVENUE —
Uj Through 00 GRADE DISCONNECT` GROUNDING
W — MONITORING 60A 240V ELECTRODE
Z Lu N D SYSTEM
1 x#10 THHN-2/THWN-2 BLACK �. 0
J 1 x#10 THHN-2/THWN-2 RED _
W #10 BARE COPPER GROUND .
Z • 3/4"EMT OUTDOOR
01 OPTIMIZER RATINGS 3 WIRES
SOLAREDGE '
OPTIMIZER MODEL:P300
MAX DC INPUT POWER(W):300
MAX INPUT VOLTAGE(V):48
MAX INPUT CURRENT(A): 10
MAX OUTPUT CURRENT(A): 15 ELECTRIC SHOCK HAZARD
PV MODULE RATINGS 0 STC THE DC CONDUCTORS OF THIS
PHOTOVOLTAIC SYSTEM ARE
MODULE MANUFACTURER: SolarWorld INVERTER RATINGS UNGROUNDED AND MAY BE ENERGIZED '
MODULE MODEL*SW-285 MONO SOLAREDGE ARRAY DETAILS
OPEN-CIRCUIT VOLTAGE(Voc): 39.7 INVERTER MODEL:SE-6000A 690.53 PHOTOVOLTAIC POWER SOU- MEP BRAND:
SERVICE PANEL RATINGS
OPERATING VOLTAGE(Vmp): 31.3 MAX DC VOLT RATING(V):500 SIGNGN O ONN INVERTER MODULES PER STRING: 10
OPERATING CURRENT(Imp): 9.20 AC NOMINAL POWER(W):6000 NUMBER OF STRINGS:2 BUS AMP RATING()): 100
SHORT-CIRCUIT CURRENT(Isc):9.84 NOMINAL AC VOLTAGE(V):240 OPERATING CURRENT (Impp): 16.2A SERVICE VOLTAGE(V):240
285 MAX N CURRENT()):25 OPERATING VOLTAGE (Vmpp):350V RED IS POSITIVE MAIN AMP RATING(A):100
MAXIMUM POWER RR
Voc TEMP COEFF(mV or°�/°C)= 0.30°/D/°C MAX AC
RATING()): 5 MAX SYSTEM VOLTAGE(Vmax):500v BLACK IS NEGATIVE BREAKER RATING(A):LST
MAX SHORT CIRCUIT (Imax):30A
Isc=0.04%/°C
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i
The Commonwealth of Massachusetts
Department of Industrial Accidents
{: I Congress Street,Suite 100 '
Boston,MA 02114-2017-
wwwmassgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): / C_ 1 ram,
Address: 361 C/o
City/State/Zipy�)n,Mro 11"A 0�3.�-6/ Phone##:
Are you an employer?Check the appropriate box: Type of project(required):
1.[]I am a employer with employees(full and/or part-time).* 7. ❑New construction
2. I am a sole proprietor or partnership and have no employees working for mein
8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
T1 I am a homeowner doin g all work m self. t 9. El Demolition
y [No workers'comp.insurance required.]
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.qI am a general contractor and I have hired the sub-contractors listed on the attached sheet:. 13.�Roof r iIs
These sub-contractors have employees and have workers'comp.insurance)
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�Oth r
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
`Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. P
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip: '
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in-the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIN for insurance
coverage verification.
I do hereby certify under t a�tn�s�dp, es o jury that the information provided Bove is true and correct
Signature: ! Date:A� `7 .
Phone#: '
Official use only: Do not write in this area,to be completed by city or town official
City or Town: . Permit/License# -
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
'+- .. 1 „"l -I :' •#.wr� 7itl �t� !'• .1 ` i� ; iJ.ram.
1
Ir
- [ i
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
TM1136DEERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsements.
PRODUCER CONTACT
NAME:
PAUL PETERS AGENCY INC PHONE FAX
680 FALMOUTH ROAD (A/C,No,Ext): (A/C,No):
E-MAIL
MASHPEE,MA 02649 ADDRESS:
28LBR INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA
SOLAR RISING LLC INSURER B:
INSURER C:
PO BOX 2623 INSURER D:
INSURER E:
MASHPEE,MA 02649 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF,SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS. - -
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MWDDIYYYY) (MMIDDIYYYY) LIMITS
GENERAL LIABILITY CH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
AMAGETO RENTED $
CLAIMS MADE OCCUR. REMISES(Ea occurrence)
ED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $
POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKER'S COMPENSATION AND WC STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-5B677050-15 11/02/2015 11/02/2016 X LIMITS
ANY PROPERITOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If Dyes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONSISPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
TOM PITTSLEY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
356 WAREHAM ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENT VE
MIDDLEBORO,MA 02346 ;
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2610 ACORD CORPORATION. All rights reserved.
I
ASAPDiesign
Engineering& ROBERT M. DE5R051ER5, P.E.
Co., inc. Consulting Engineer
508-946-3561
155 Eaet Grove Street • Fbot Office Box 649 Fax 508-946-1655
Middleborough, MA 02346
October 7, 2015 Project No. 2015-299
Mr. Thomas Pittsley
Synergy Home Energy Solutions
356 Wareham Street
Middleborough, MA 02346
Re: Review of the Solar Panel Installation and Support Framing Members
for the Structure Located at 57 Halyard Way, Centerville MA 02632
Mr. Pittsley:
You asked me to evaluate the support system for the installation of a solar panel array on
the roof of the existing structure at the referenced location. The information you have
provided me is for the(Sunmodule Plus SW 285 Mono) solar panels that are to be
mounted to the SnapNrack Series 100 UL Roof Mounting System. The mounting rack
system will be attached to and supported by the rafters located below. You have provided
me with a sketch depicting the layout of the solar panel and rack system.
The home is a conventionally framed Cape-Cod style home with a full shed dormer to the
rear..The solar panels are supported on a(2) rail roof mounting rack system. The existing
rafters are 2x8 spaced at 16"on center with a unsupported span of approximately 13'-0".
The mounting racks support a portion of the tributary loading from the solar panels, as
well as the code imposed loads on the system. The rack system will be attached to the
existing 2x8 roof framing members, and the rafters will support the point loads from the
mounting racks.
The existing roof rafters support the loads from the roof mounted solar panel system is
consistent with the requirements of the Building Code for existing buildings, and if
constructed as specified herein, consistent with the plans, and according to good
construction practice, the roof rafters will meet the structural requirements of the
Massachusetts State Building Code, 8th Edition. If you have any questions regarding this
report, or if you require additional information, please do not hesitate to call.
Regards,
�a
Michael R. Shaheen � ���� �•zr�
.sue q
ROSER a M.
' DESR( 3.`EQT
E m
,U_;i UtL C10
mod? �( .36770
S/ONAL L�
' r H
Town of Barnstable *Permit#�I V DOI Z
® m ,� Expires o,the fro 'sue date
E PER:: Services Fee
angxszABM
� MAB& OCT _9 20?4ichard V.Scali, Director
1639. ,�� t TT
ArFD MA'I p '
TOWN OF BAHNSTA Laing Division
Tom Per , "�O,Building Commissioner.
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
f f Not Valid without Red X-Press Imprint
UJMap/parcel Number 9 Y ,
Property Address 5 7 J( ✓'l
[Residential Value of Work$ �, Foci, ° Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address P4 ° ��
1 •„
J .K:;'A
Contractor's Name A L la, �`' � Telephone Number 50S AUlr S3
Home Improvement Contractor License#(if applicable) Email: 'C'C ytl fie, .
Construction Supervisor's License#(if applicable) C,:S— /d?A 7
❑Workman's Compensation Insurance
Check one:
I am a sole proprietor
❑ Lam the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box) '
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over- existing layers of roof) '
Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of th Home Improvement Contractors License&Construction Supervisors License is
- .�pirered.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
• fie d�rvnaoncuea C>!i a cUrett
zi Office of Consumer Affairs&Business Regulation
t ME IMPROVEMENT CONTRACTOR
I ;egistration 171,899 Type:.
xpiration , 41301-2 DBA
FERULLO REMODELINGr_ 1
�;. MICHAEL FERULLO `
40 GRISTMILL PATH
M_ARSTONS MILLS,MA 02648"
Undersecretary
" a
Massachusetts Department of Public Safety.
Board of Building Regulations and,Standards '
. Construction Supenisur"
License: CS-107347.
MICHAEL FERULLO
40 GRISTMILL:PATH
Marstons Mills MA 02648 'a
Expiration
.�. � ". 09/09/2017
�. commissioner
"
. t
. . .a
icense or registration valid for individul use only before the expiration date. If found return to.
Office of Consumer
Affairs and Business smess Regulation
s 10 Park Plaza-Suite 5170
i
Boston,
n,MA 0211
6
i ..
1.
Not valid without signature
i "
- 1
4
"s.
9 Massachusetts -Department of Public Safety
Board of Building Regulations and St
andatds ..
Construction Super,isor . -
1 License: CS-107347 ..k
r
NIICHAEL FERUI�LO.
40 GRISTMILL PATH.;.p
U �
Marstons Mi11s MA 02648
- .
Expiration '
/. .� •; 09/09/2017
Commissioner.
{
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111 '
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: L10 --
City/State/Zip: , c4,49 Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.ElI am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.�I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees - These sub-contractors have g. ❑Demolition
workingfor me in an capacity. employees and have workers'
y p �' # 9. ❑Building addition
[No workers' comp.insurance comp.insurance.required.] 5. ❑ 10. Electrical repairs or additions We are a corporation and its ❑ P
3.❑ I am a homeowner doing all work ` officers have exercised their I L❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Other
comp:insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site -
informatiom
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under th pains andpenalties ofperjury that the information provided above is true and correct
Si ature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Perniit/License#�
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to cant'workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel, #617-727-4900 ext 406 or 1-877-MASWE
Fax#617-727-7749
Revised 4-24-07
www.mass.gov/dia
to
sAexsrn>sM ;
�,� Town of Barnstable t.
" Regulatory Services
Richard Scali,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,'MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, -INK 11✓ , as Owner of the subject property
hereby authorize I i 19 T-qAc to act on my behalf,
in all matters relative to work authorized by this building permit application for:
57 ICI�rv� . (Ake (-bA Ui
(Address of Job)
lo_ R- l
S* atur of Owner ' Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
QAAWILESTORWbuilding permit fomulsmokecarbondetectors.doc.
Revised 050412
Town of Barnstable
Regulatory Services
pF h Richard V.Scali, Director
Building Division
* aAMffnsM Tom Perry,Building Commissioner
M+ss.
i639• x� 200 Main Street, Hyannis,MA 02601
Ep www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required
shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);
provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act
as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of
a supervisor(see Appendix Q,Rules&Regulations for Licensing'Construction Supervisors,Section 2.15)
This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed
persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,
as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a
Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend
and adopt such a form/certification for use in your community.
I
I
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel �Ci Application # oC
Health Division Date Issued
Conservation Division `' Application Fee
Planning Dept. Permit Fee A �
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address 57 '—�1AyP� 1rJd9 `7
Village
Owner 1�1"Ie,'Ek Address 1917 ("ah
Telephone Y— Z3
Permit Request VA)
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay' M2 o
CUO
Project Valuation 9co Construction Type "'
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach s'up orting d umtation.
Dwelling Type: Single Family 3P Two Family ❑ Multi-Family (# units) M1
Age of Existing Structure 30 5e.s Historic House: ❑Yes )[,No On Old King's Highway: 0 Yes WNo
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
p
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing —new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name Telephone Number 5OS - 7Ll 782--
Address S7L1 /� �� > License #
Lt,A;Ze,�eI14t-L Home Improvement Contractor#
Email 57 F,6na4 af2!r?,NF r Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 7✓0r7q- 5'�=,F9-^)
SIGNATURE — d DATE Gil'
V. /y
FN
_ FOR OFFICIAL USE ONLY
wx
APPLICATION#
DATE ISSUED
,r
i MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:.
FOUNDATION
w FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
16
PLUMBING: ROUGH FINAL
I, GAS: ROUGH FINAL
I; FINALBUILDING
Q T-ECLOSED OUT
ASSOC-1ATION PLAN NO.
.cne rt.ummunweuan ojtrlassacnuseus
Department of Industrial Accidents.
Office of lnvestigadons
` 600 Washington Street
Boston,HA 02111
www.mars govh9a
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/oTmdzatioaandmduaD:
Address: 5-7
6%&12—
City/State/Zip: �£-�� �� e,4 Phone#: 54 71/y- 7a 23
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I
employees(full and/or part time).
* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sh=t 7. ❑Remodeling
These sub-contractors have .
ship and have no employees �. 8. E]Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp. insurance comp,insurance J
required.] 5. We are a corporation and its 10_❑Electrical repairs or additions
officers have exercised their
3. I am a homeowner doing alI work - 11.❑Plumbing repairs or additions
myself: [No worker' comp. right of exemption per MGL 12. Roof repairs
c. 15 ,
insurance required.]t 2' §14 and we have no( )employees.No workers' 13.❑Other
comp.insurance required.]
*Any.applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this a;,adavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name ofthc sob-eont'mcirrs andsW--whether or not those entities have
employers. If the sub-contractors have employees,they must provide their workers'comp.policy nnmbMr.
I am an employer that is provir&ng workers'compensation insurance for my employees. Below is the policy and job site
information-
In si=ce Company Name:_
Policy if or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip: -
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK'ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of --ds statement may be forwarded to the Office of
Investigations of the DIA,for insurance coverage verification_
I do hereby certify u ndA the pains and penalties of perjury that the information provided ab' is true and correct
S _ t Date: � ( /L1
Phone#: S�y _ 7Y'y^ 28)-3
Official use only. Do not write in`this area to be completed by city or town ofjUdaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrieal Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions ..
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more
of the foregoing engaged in*a jomt enterprise,and including the legal representatives of.a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelliIIg house of another who employs persons to do maintenance,const ructian or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
< as -
MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced.acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfuunaace of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to youir''situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their ceriificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date The affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the m nber listed below. Self-insured companies should enter their
self inctirance license number on the appropriate line.'
City or Town Officials
Please be sure that far,affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out m the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple por itllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under`Job Site Address"fhe applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT regwred to complete this affidavit
The Office of Investigations would like to drank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call,
The Department's address,telephone and fax number-
The Commonwealth of Massachusats
Department of Industrial Aocicl is
Office of 7�p.'ue&tigatiom
60-0 washingtou met. '
Boston,:MA 02111
Tel.#f 17-727-494Q ext 406 or 1-V7-MAS�L F
Revised 4-24-07 Fax 9 617-727-7749.
v .m .gGv/dia
Town of Barnstable
' Regulatory Services
�oF*iE roiy� Richard V_Scali,'Director
Building]division
* sARNST LK Tom Perry,Building Commissioner
MAss.
200 Main Street, Hyannis,MA 02601
pT�O �a www.town.barnstable.rna.us
Office: 508-862-4038 Fax: 508-790-6230
.HOMEOWNER LICENSE EXEMPTION
Please Print'
DATE: �y, ,'� > ,,perT s
JOB LOCATION: <7 1 7!' o 60fiC9.vre.,ey;,t-"
number �_ street __ _ village ��y /
"HOMEOWNER": V `��I /s �LBTR Sf�'7�Ll—7�`L� �t.0 .�.�G� �� �6
name home phone# `work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied iep d dwelliD as of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations. _
The undersigned"homeowner"certifies that he/she understands the Town of Bamstable Building Department minimum inspection
pro dare and requirements and that he/she will comply with said procedures and requirements.
Sign re of omeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,RuIes&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor_ The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities, many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
Town of Barnstable
' Regulatory Services
MASS..IE Richard V.Scali,Director
o3 9. Builffing Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner Of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job)
" "Pool fences and alarms are the responsibility of the applicant. Pools
t
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
Print Name Print Name
Date
Q TORM&O W NERD ERMIS S IONPOOLS
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094.641
PLANMORTGAGE INSPECTION ..PLAN PURPOSES ES ION Y.ETHIISDIS FOR
ANK INSO RTUMENT
SURVEY AND IS NOT TO BE USED FOR FENCING,
LOCUS 57 HALYARD WAY CONSTRUCTION; DEED DESCRIPTIONS, 'RECORDING,
BUILDING OFFSETS OR PROPERTY LINE DEFINITION.
CENTERVILLE, MA
REF PLAN BOOK 379 PAGE 70 fN � ss9�
PLAN PREPARED FOR boa JORN yG�
CAPE b0l) COOPERATIVE BANK DEMAREST,.JR; w
.�No.36853d
SCALE 1"=40' DATE 6/16/2011
l D
OWNER OF RECORD: KEITH J. & ANN MARIE ALLAIN. u
THE DWELLING 'AS SHOWN COMPLIED WITH THE t3ARNSTABLE DATE REG ND SURV OR
ZONING BYLAW BUILDING SETBACK REQUIREMENTS WHEN CONSTRUCTED.
OR EXEMPT FROM VIOLATION UNDER M.G.L. TITLE VII, CHAPTER 40A,
�
SECTION 7. �av llv 6. UL�9a REST J .sP.L.S.
THERE ARE NO VISIBLE EASEMENTS OR ENCROACHMENTS OTHER THAN PROFESSIONAL LAND SURVEYOR
UNDERGROUND SITE UTILITIES OR AS NOTED ON THE PLAN. 338 MAYFAIR ROAD
THE DWELLING IS PiOT LOCATED IN AN ESTABLISHED FLOOD HAZARD SOUTH DENNIS, MA 02660
AREA AS DEFINED ON F.E:M.A COMMUNITY PANEL # _250001 0015 C Y (508) 398-6717
--�— FILE=1 10008.DWG
i
I sr:# OF
BAR
CL%PE COD,
TABI
41
• FIBER GLAiS SEAMLESS WRAYFOAM SUSPGNDM,- y • • '
DAM "wERS msuuYION CEILINGS Csa _,�
1-900-696-6611 4s_
Town of �n o7k� � • F
Regulatory Services =t ,
Building Division M
Address- :.
Address 2
Date:
Dear Building Inspector
- Please accept this Affidavit as documentation that Cape Cod_Insulation;Inc.performed& ^ ;f
completed the insulation and weatherization work at the property listed below. Cape Cod
Insulation did this in accordance to the specifications listed on the building permit
application. All work has been inspected by a certified Building Performance Institute,
(BPI) inspector.All work preformed meets or exceeds Federal& State Requirements: ;
Property Owner Property
Address
lee ii lIr
Insulation Installed: Fiberglass Cellulose R-Value ; Restricted Unestricted
g
u . j
Ceilings
slopes ott�tA ck NA
ii
Floors { .) *"<•r ( ) ( - )`
Walls ( ) 37,F ( ,•) :.' ( ;I. ) `( , ) v `'{ ) ,�r
Sincer I ;
, < ...3 .. t .. r , . .i.' -'tea. •
Henry E Cassidy Jr,President` ,
Cape Cod Insulation,Inc. "
L
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION of L/A0/12
Map Parcel Application
Health Division Date Issued `
Conservation Division Application Fee -�
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _Preservation /Hyannis
Project Street ddress
Village o
Owner 211 I t4 Address
Telephone_ - �i
Permit Request m 01fl cdltdose, 1v 997 Womil
log
, ,,�- � ��!� �ioul��� �P� ,�� �! �l7 •, � jam ��>�
oie �`r°
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type �(�/ �✓
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing neww.3
r�� N
Number of Bedrooms: existing _new r~ d
Total Room Count (not including baths): existing _new First Floor Roorn: ount'-1z7 '
Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/ce l stove ❑YEs ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑ e J ing knew- size_
10 rn
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
r.
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Names*, -r- -D I -6d 64ov Telephone Number ' �gg- ?K—l Z
Address` �✓� License # G 60 �a
Gl / Home Improvement Contractor# C��✓e�
Worker's Compensation* 06
ALL CONSTRUCTION DEBRIS RESULTING F OM THIS PR JECTaILLBE TAKEN TO
�J
SIGNATURE DATE �'�
c
s
s
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAR/PARCEL NO.
,
r
.i
e
ADDRESS VILLAGE
OWNER
r -
DATE OF INSPECTION:
;FOUNDATION
FRAME
,INSULATION.
z
FIREPLACE
k
ELECTRICAL: ROUGH FINAL
'M PLUMBING: ROUGH FINAL
GAS:- = 1.1:, ROUGH; ;:-- FINAL
"FINAL BUILDING .. r� �'•
DATE CLOSED OUTw
s
ASSOCIATION PLAN NO.
_ �` t� Sa4c1 ild
10 Park'Ptaza- Sulte-5170
N Boston, Massaclrii5�etts 021,16
I Lorne IniProvenient Cajlt!actor Registration.
Registration: 153567 «'
4 +� 1Vpe Private Corpoi,ation` .
Expiation. 12/15/2012 1'rg-206433
CAPE COD INSULATION, INCHENRY -
CASSIDY
455 YARMOUTH RD.
h-IYANNI �
5 MA 026.01
Update Adelr ess and rehir n u-d. rd t-k r t.asuu tur rlr;iugc.
L Address :I- I Renewal.' 113rnpfuyurrut =I �u�tC'rud
iii(i -!'n,iruur •(Ifair, tiu.N, ell , RegulitioII LrculSc of rewstrationNalid for itt;l Tuft.! w r ,s!y
i10MC11 P b� fJ`I``� f A�f�j$`cclic�ar�(s + before the,e pii,ation date. If found return ht, :� t
Registration; I ti3567 Type: f' Office of C011sunier Affair's and Business Regulation,
I Expiration: 12/15/2012 Private Corporation 10 l ark I'I iz,r-Suite 170
Boston,NIA f12116 s �:
vUINSULA[')ON, INC {
• ti
610U I1 I RC).
C.lndersecretarY ( [ abd tth tSr Cure s .
; t x
IN-hssachtjs�tts - Nparuncill of Public•safet) '
- l3uarc) of 13ui1(liirg, R rlulafions aIld Jrtn(I:u-dS _.
Y ..
Construction Super visor'License, '-,-
License: CS ,`..100988 '
HENRY`CASSIDY
8 SHED ROW .•
WEST. YARMOUTH, MA•02673
s -
Expiration: 11/11/2013
,' TrN> 7620 �r
,
Client#:4597 CCINSUL
AeORD CERTIFICATE OF-LIAR' ILITY INSURANCE. DATE(MMIDDNM)
210212012
THIS CERTIFICATE(IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE•ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER-
IMPORTANT:It e certificate ho1der Is an ADUITIONAL INSURED,the po Icy les mus a endorsed.It SUk3HUUA UIUN 15 WAIVED,su iec o
the terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s). . r
PRODUCER
f NAME: Margaret Young _y.
Rogers 8k Gray Ins.-So. Dennis 'PHONE . FAX
(ac No, ML 508-760-4602 FAX
No 434 Route 134 ,.>.IL ADDRESS: _. _ y-_ );,877 816-2156
P.O.Box 1601 PRODUCR OUngma@rogersgr'ay..com
South Dennis,MA 02660-1601 1 CUSTOMER ID u: _
.. .. .¢, `t •„ -; INSURER(S)AFFORDING COVERAGE a NAIC#
INSURED INSURER A:Peerless Insurance #• .18333
Cape Cod Insulation Inc 455 Yarmouth Road INSURER B:Ohio Casualty Insurance Company
w • - - . • �
Hyannis,MA 02601 INSURER C:Atlantic Charter Insurance
INSURER 6:Commerce Insurance Company;, 34754
INSURER'f i
INSURERF:-
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:`
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED-
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH.RESPECT TO WHICH THIS CERTIFICATE MAY BE
ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF
SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. • t
NSR ADDL SUBR POLICY EFF" POLICY EXP
LTR _ _aAN El y
A GENERAL LIABILmr CBP8263063 * F 04101/2011; 04/01/2012 EACH 0CCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
• - PREMISES(Ea occurrence) .$100,000
CLAIMS-MADE X OCCUR
------ -- -,. r _. MED EXP(Any one person) _•.;$_5,00_0_
' • {" i - PERSONAL&ADV INJURY $1,000,000
„ GENERAL $2,000,0M-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- AGG .$2,000,000
PRO- t $
D AUTOMOBILE LIABILITY +• 11MMBCKVMK O4/O1l2011. 04l01/2012 COMBWEDSINGLE LIMIT•.. $ -
ANY AUTO n' (Ea accident) 11000,000 ,
ALL OWNED AUTOS BODILY INJURY (Per .person) $ -
. � .. ... ..
�• a k''._• F BODILY INJURY(Per accident)' $ - -
X SCHEDULED AUTOS. •,� , , _, _
X HIRED AUTOS
PROPERTY ' DAMAGE
',. (Per acaderd) " $ r
X NON-OWNED AUTOS --•' • ' - - " '- '. � -
a
- -
B UMBRELLA LIAB X :OCCUR -; - •UUO1254514645 ^' w ^04/0112011 04/0112012;EACHoccuRRENCE,4 $1;000,000, r
EXCESS LIAR CLAIMS-MADE
AGGREGATE • -.$1,000,000 -
DEDUCTIBLE a
X RETENTION $ 10000
)[
C WORKERS COMPENSATION WC STATU- OTH t
WCA00525902 + 06l30l2011 t
AND EMPLOYERS'LIABILITY Y/N s - - 0/2012.X..,TORY LIMriS 1 ..ER -
06/3
ANY PROPMETOR/PARTNERIEXECUTIVE ` ' t '-, r E L EACH ACCIDENT $SOO,000
OFFICERIMEMBER EXCLUDED? N/A �,„
;.
(Mandatory in NH)
If yes,describe under m { a e E.L,DISEASE-EA EMPLOYEE 1.500,000
t -
OFSCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT -s 500.QOO
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) ,Y
Workers Comp Jnformation Included Officers or Proprietors $
CERTIFICATE HOLDER " CANCELLATION
,..SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE'
EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ti ACCORDANCE WITH THE POLICY PROVISK)NS. f °
} ` z AUTHORIZED REPRESENTATIVE
01988-2009 ACORD CORPORATION.All rights reserved.
ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S77368/M68179 . , MEY
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rn,t ne.i�whu,'ubinu this ttlfidavit in�icaligGlhey arc domg'�il „ �d Lhcn hire buLsidc r.an[raclofs must su�lnll n nc.�s'iAllltluvll-inChl`eunp,;uiU •
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to ,j,.'7(1 00 rt day aguix,isc ncc violator. kit-'adviscci'ihst•:; copy of this staleakut iliac/.bc. forwal dc-, tc) Ihc,i;l(TICC.of : r
:;tl ;l,it„ns uCQic DIA fm it)surancc.coycraE;r. v ntic.,n
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I!Mci d 11.Se otlly.• !)G tIUi lttrtlP'Irf dies area, to bt by clfy`Jr Il11Gr19fJfIt.1QL
i; `awn '' PerinitiLicenSCr,r :' -- — ------ --------
I., u t��';i.. Uluril;Y (t.irc.IC Unej
iI C 11.c'.UI.t:l'I b IIditag Depar nIeht 1. l.It;rtom) Clerk4. l;le tricul lrupectol' ti C'6t.lrrlhillls ';_,:rur
I.
Phone
mass save CONIMCTOH
Senn erow9!•Fn,r4,err.-,a:rer - ��
PERMIT AUTHORIZATION FORM
�ekLo 1 w
(Owners Name, printed) owner of the property'located at: -
' f
(Property Street Address) (CitylTown)
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property.
Owners S 'nature
rz-
Date
FOR CSG,OFFICE USE ONLY
w -
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project: -
Parti pating Contractor
Date
Rev.12132011
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION '
., Map ' P el Q �- Permit#
,,health Division j
! Date,lssU.
,conservation Division Fee ��• "
..-
�Tax Collect o^ - Allot hk IC S, GT Ga@c .
INSTALLED IN °
Co
g��L��,��� f �.�` � =�y3r7o
-"Treasurer /Y o4o � WITH TITLE 5
Rffmftgftpt-.——I . ENVIRONMENTAL CODE AND
TOWN RE n
D - �S
b ,
Project Street Address
Village
Owner K F1:f,A. Address
Telephone
Permit Request ::Y�e! r7ra
�c lilit.
Square feet: 1st floor:.existing proposed 2nd floor:existing _ proposed, Total new 29
ooU - 700 L"8
Estimated Project Cost o�v Zoning District Flood Plain Groundwater Overlay
Construction Type A EX ���WL-
Lot Size N�,a Grandfathered:, 0 Yes ❑No If yes,attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) r
Age of Existing Structure Historic House: ❑Yes *No On Old King's Highway: ❑Yes No
Basement Type: XFull ❑Crawl , ❑Walkout ❑Other
Basement Finished Area(sq.ft.) /J� Basement Unfinished Area(sq.ft) NL4 8
Number of Baths: Full:existing new Half: existing new
Number of Bedrooms: existing new
Total Room. Count(not including baths):existing new -' / First Floor Room Count
Heat Type and Fuel:XGas ❑Oil ❑ Electric ❑Other'
Central Air: ❑Yes .�4No Fireplaces: Existing 1/< ' New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new ,size Pool:.❑existing ❑new size Barn:❑existing ❑new siz.e
Attached garage existing ❑new sizeld_lq�Shed:❑existing ❑"new size Other:
V y • •
Zoning Board of Appeals Authorization O Appeal.#' Recorded❑
Commercial ❑Yes ❑No If yes,site plan review#
-Current Use Proposed Use '
Bi4LDER INFORMATION,
y ✓ .
Nam ?J) i► 1: Telephone Number
Address License#
Home Improvement Contractor# Z:
�- - Worker's Compensation# `
- o7 �y
LL CO S RUCTION DEBR S RE LTIN ROM THIS PROJE TWILL BETAKEN TO
SIGNATURE tZ DATE l/
' s
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
s •r. , ` F
ADDRESS ". +� "VILLAGE'
{ OWNER . . , � :�• _ �' ,� � . . _ . ._ :. ., � - , .., --, • ,j•
• `•ate: . z i - " + -: :.•.. _
DATE OF INSPECTION::
,.
70
FOUNDATION,
a
FRAME
INSULATION
} � � 'nn' ryYk , n1• "' � ` $' ni .•� r f i f { • • .' 4k r,
FIREPLACE
ELECTRICAL: ROUGH �:. _ - FINALIj
PLUMBING: ROUGHI FINAL
GAS: �' ROUGH: ,, " FINAL " ?
FINAL BUILDING
DATE CLOSED OUT, i ,A (" y _ -t • . � _ } •
ASSOCIATION PLAN NO.
- ' .. : -fir ' � •' • , r • ~
L
Town of Barnstable *Permit lt �S I�
atNE tpk, �p 6 hs from> ue date
�� do b C�
r �
Regulatory Services
w •ARNSTABM
y M^QQ Thomas F.Geiler,Director
�pTEB 39,t
Building Division
Tom Perry, Building Commissioner DE-C
200 Main Street, Hyannis,MA 02601 7"ovvjv 2004_
Office: 508-8624038 Op amivs
Fax: 508-790-6230
EXPRESS PERT APPLICATION - RESIDENTIAL ONLY
MI
Not Valid without Red X-Press Imprint
O�(D
Map/parcel Number LDA�(
'M n
Property Address ' �r yam® C i
Value of Work 7 G9
residential
;Owner's Name&Address- /�Trr /? f'Y AJ _
tj60- Telephone Number
Contractor's Name
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
axorkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
InsuranceP y Com an Name /7 G'� !s � : �®®�>�9®✓��t`'
a
Workman's Comp.Policy#
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
36
❑ Re-side a
eReplacement Windows. U-Value (maxim'm•44)
❑ Other(specify)
*where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
Signature
Q:Forms:expmtrg
Revised121901
°F T Town of Barnstable
Regulatory Services
BAM� ass � Thomas F.Geller,Director
E1639. Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-8624038 Fax: 508-790-6230
Property Owner Must Complete and Sign This Section If Using A
Builder
I, khErl-f A�A/A ,as Owner of the subject property
hereby authorize _Nl� to act on my behalf,
in all matters relative to work authorized by this building permit application for(address of
job)
Signature of Owner Date
Print Name
Q:FORM&OWNERPERMISSION
i'
x
��ee Po7.vneo�zcuea�l! o��/�aaaaclu�aek�
Board of Building Regulations and Standards j
HOME IMPROVEMENT CONTRACTOR
Re9i$ �,a 100503
a /19/2006 . 1
element Card
CARE FREE H
ROBERT PICK -
231.9:Huttle�gtolj:ave _
ZZ"
Fairhaven,MA 02719
Administrator
l
f
-- r
Town of Bggjq�tabAeSTABLE
GF THE Tp�
�� do Regulator���e��r�c�es
� 9: 3 !
Thomas F.Gei e , ire
•nxrisTnSTAsi.E,
9 M g Building Division
i639• ♦0
.etEO MA'S A Tom Perry,Building-Eorn_�mi�ss�ioxer
MO Main Street, Hyannis, 1��2� i
Office: 508-862-4038 Fax: 508-110-6230
00
PERMIT# FEE: $
SHED REGISTRATION
lI `` 120 square feet or less I
WA C�Kf�rr �IQ
Location of she (address) Village
Property owner's name Telephone number
g' X uk iq�06�
Size of Shed Map/Parcel#
I
l0 a
Signature Date
Hyannis Main Street Waterfront Historic District?
Old King's Highway Historic District Commission jurisdiction?
Conservation Commission(signature required)
PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE
COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE.
PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS.
THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN
Q-forms-shedreg \
REV:121901
f
LOT 22
LOT 23
00 �
LOT 24
EDFORD T CO.
NEw BON Lj" wiDE % LOT 30
& 5D05NT 210
EAS N
w
LOT 29
LOT 28 ,� \
N � oq
4.:5 3
; \
141
' 57;; := x
b ;;N,,i,•3g 2 o to
i t� iQ o
0
' R = 35.14'
y L = 28.63'
10'� 164
L i pg4.6
- tR yoAD
YARD
14AL
RES. ZONE: "RC" This MORTGAGE INSPECTION Bann is For
FLOOD ZONE- "C"
TOWN: --CEW—M� LL _______ k Use Only
DEED REF: -MJV�3. p_______--- REGISTRY OWNER: If ' _J_ A1V�V_MZIRI_9�L_Al1V________
DATE: _ZQ=0_6_-� ____-- ----BUYER: - 'p71Y.91YCL'__-__--
-------- PLAN REF: ..379_70-------------SCALE:1,�-----;------
I HEREBY CERTIFY TO LQ Ip ,F B6Ly1C __—_—____— 40---FT.
FOR SA VINCS _____THAT THE BUILDING ��'� of
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS s YANKEE SURVEY
SHOWN AND THAT ITS POSITION DOES ____ CONFORM S PAAU1 CONSULTANTS
TO THE ZONING LAW SETBACK REQUIREMENTS OF THE MERITHE y
TOWN OF ___�ARSL9�LE_____ 143 ROUTE 149__AND THAT 10. 32098
IT DOES_ NOT— LIE WITHIN THE SPECIAL FLOOD HAZARD p MARSTONS MILLS, MA. 02648
AREA AS SHOWN ON THE H.U.D. MAP DATED 8_j,9 _ ,p F�ISTE��SJ� TEL' 428-0055
250001-0015—C a Lwaa FAX 420-5553
PAUL A. ----- THIS PLAN NOT MADE FROM AN INSTRUMENT
SURVEY NOT TO BE USED FOR FENCES ETC. 25290 SDS
P
�, � .
� .. �< -
fi g ��
.. �, � - �,
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��
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i
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r �IHE
: . The Town of Barnstable
ELMMASABIA
� Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
Permit no_Itoelg
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,.demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: C/1Ac2� Estimated Cost
Address of Work: LAq,
Owner's Name: \fa
Date of Application: d
4)745_
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job Under$1,000
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as e agent of the owner: / .. _'� 7 C
Date Contractor Name Registration No.
OR
Date Owner's Name
q:forms:AfFidav
I - The Commonwealth of Massachusetts
_Z
Department of Industrial Accidents
Olflef o/ImrstloaUoas
600 Washington Street
- - Boston,Mass. 02111
_ Workers' Compensation Insurance Affidavit
name:
location: h 0 0
s - - /city
h e# �
❑ a homeowner performing all work myself.
I am a sole etor and have no one worku in achy
❑ I am an empl rkers co ensation fo 1 wo on g..... ......... .....mP:. .::..:........ ........... P. ....... .......this job.........
>`.
<:::::':
-company
name::' , � ,'>.:>'�;��•:•:;:.:::::�:!::.>?>:. e:. .::.:.._.
:s re .. ::... ........ .............
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is P
i>siiran
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sole proprietor,general contractor,or homeowner(circle one)and have hired the contract=listed below who
have
the following workers compensation polices:
..•x
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:::::::::::i::::::.}i}?i•:i?:4�•?:Li}i?'•i??iv:...}.::nv:::::::;:.y:..::.:.:�:.:Y::•r.r:::::{:::::i:•Xfiiiii:S:
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Faibu a to seeeo:a coverage as n:gdted ffiider 3-.eQEom 2 o£P.d03..".6. �ava•"^s z! laat omaities mf m IDs�vP::0 5:.'M` m �
ama yeses' or®mt as wa as dvll peaaitles in the form of a STOP WORK ORDER 9n and a e of$100.00 a day against me. I mderstmd that a
copy of thb may be forwarded to the Once of Inyestlgatlom of the DU for coverage veridCatlon.
I do herellj+c fy under the p ' I enaldes of inforneadon provided above is trrr� d can
Si n l -
gns ,�Z�✓� ' Date _
Peat na�e Phone#
official use a do not write in dd;sera to be completed by city or town official
city or town: permit/Rceme# ❑Bu Bding Deparlmmt
❑checkif immediate response fa regodred Ogg Board
❑Selechmn's Office
❑Health Depaefmmt
contact person: phow q,
_ ❑Other
4mudsrosrua
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any co=-- .
of hire, express or implied, oral or written.
An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver c:
trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has
not produced amcptable evidence of compliance with t te_insurance coverage required. Additionally,neither the
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
_being requested, not the Department of Industrial Accidents. Should you have any questions regarding the`law"or if you
are required to obtain a workers' compensation policy,please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be.sture to all:i:: w�li=ue-use*e as-2 efercmce number:. 11e affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should any ou haveions.
Y �N�
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Me of Imlesugallons
600 Washington Street
Boston'Ma. 02111
fax#: (617) 727-7749
phone#: (617) 7274900 ext. 406, 409 or 375
;j' fee Lo�rv»zonurea a�✓�aaoac�uveka
`- 671
DEPARTMENT OF PUBLIC SAFETY �.
i CONSTINT- N SUPERVISOR LICENSE
Neer, Expires:
--- -- estr t$ATo 11 1
yr.
} PO BOX B41 .. R
MASHPEE� NA 12649
4
Wig.
ROVENENT ONTRA TOR '
F fi
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TOWN OF BA1iSTABLE - - --- - -
BUILDING PERMIT
PARCEL ID 194 066 GEOBASE ID 32291
ADDRESS 57 HALYARD WAY PHONE
CENTERVILLE ZIP -
LOT 29 BLOCK LOT SIZE
' DBA DEVELOPMENT DISTRICT CO
PERMIT 34482 DESCRIPTION CONVERT GARAGE TO FAM ROOM ADDgEDROOM OVER
PERMIT .TYPE BREMOD TITLE RESIDENTIAL LT/CONV ./� /9.9 ,�-LdJ_ -`
4 -
CONTRACTORS: F I NN, JOHN W. JR. Dep 4 ent of Health, Safety
! ARCHITECTS: and Environmental Services
TOTAL. FEES: $62.00
BONDl $-00
C°;QNSTRUCTION COSTS $20,000.00
434 RESID ADD/ALT/CONY 1 PRIVATE P 0
- * BARNSPABLE, ;
' MA83.
i6gq. �1
FD INI�►I
BUILDIN IV SI
BY
DATE ISSUED 1,1/02/1998 EXPIRATION DATE
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. EN-
CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR
ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS
PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF FOUR CALL INSPECTIONS REQUIRED
FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE
1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED
2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU FOR
ELECTRICAL,PLUMBING AND M FOR
(READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS.
CH-
3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE.
4.FINAL INSPECTION BEFORE OCCUPANCY.
VISIBLEPOST THIS CARD SO IT IS
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
1 1 1
2 2 2
3 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT
2 BOARD OF HEALTH
OTHER: SITE PLAN REVIEW APPROVAL
WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS
THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY
VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA-
TION. NOTED ABOVE. TION.
The Town of Barnstable
. a
Health Safe and Environmental Servtcr:..
. $ Department of Safety _.
�.' Building Division
" 367 Main Satre,Hyamais MA 02601
- C=Z=
Off!= 308-790-C27 Hiuidiq
F= SOB-790-6Z30
For otIIce use Only
Permit na
Dare . AFFMAVIT
ROME 3WROVEMENT'CONTRACI'ORLAW
WPPLEMENT TG PMUArr APPLICATION
UGL.t: 142A requires that the '=eeonstracdaa, aitesstfons, tenovatlon. repair, moderuizttian-
conversion. improvement,,mmovai, demolition. or construction of an addition to any pre-ezisting
owner occupied tmiiding containing at least one but not more than tbur duelling traits or to
strataures which are sdiacent to such residence or building be done by registered connectors. with
certain czccptions.Ziong with other requirements. i
Type ofWork
&L Cast , t�
9 L'L�
Address of Wark
Owner's Name L d N
Date of Permit Appfl=tion:
1 he by certify that: .
Registration is not required for the following re son(s):
t
aric mduded by taw
_Job under 51.000.
Suiiding not owner-occupied
weer palling own permit
Notice is hereby given th c
.OWNERS PULLING THM OWN PERMIT OR DEALING WrM ONREGMTERED
CONTRACTORS FOR ARBITRATION PRO GZAI+ORRANTY F'QNDW[JNDER MCI.242A ORK 00 NOT �
ACID TO THE•�
MGM MWER PWALTZS OF PERJURY
i hereby afffy{hr_.permit as the agent of the owner:
lt.
<N� ii� l
one Contractor Name Rtfon No.
OR
Date Owners iYamte
-. The Commonwealth of Massachusetts
-
I_ __ Department of Industrial Accidents
. _= - Olflce ollllmestlgat/eas
600 Washington Street
-- > Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
i
name: Q ti s�J
location: //]
A L
cityhone# d B
AA
❑ I am a homeowner performing all w rk myself. .
❑ I am a sole netor and have no one workin in actty m�
%/�%%%%%%%%%ly
% %%% �,
I am an employer roviding workers'compensation for my employees working on this job.
.<: :..:.::.::.
.......:::: :.
.. ..........::. ::.;::.;:.:.:.
..................
m sn name..:.
address. t+
tisa'rance ca ....
oIt # ...: 2,5711--f....
:.:. , k
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have `-
the following workers'compensation polices:
com an name:: ":.;::: ...........................................
v 1) -::::::::: ::::::::::::.:::::::::::.::
3 z�< »���
'�IIress "``' ?� s> ''iii:`�'i'>i ii::` : i % >! <``isj}%2`:--:.. i'i? ::''?iy:< is :i .?ii2<iiiii iiii% < ?' '# 3i3?'i2 isic'::?' ::i-:i"..... i%`i iy...- ? j ..:.:::::::ad _ .... :.,_..:....:.:.....,,,:...
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:gLfi:':':;i::`:1:.:,..... :;::::_`::::::i::.`-ii:i:::?y: :::!Y::::::::!:::;::;i:;'::::::i:y;;;:;:;:;`i`: %.:::.::::::::::i}: .....a+'::;`j::�:':!:i.'j;j:ii:'ii:«<em ': .��� �i:y�i:;:.. iii:t:i::ii:�ii:?hi:t:::isi::t:i::ii:�:i:::::::::isi'i......:Y�i:'i\<:Yri}liTiY?i^'.::':::::11�tnle#
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.... .... .............. .... ................................:::........ :::::...... ........... .........::.:
........................................ ......:..............v::........:::•:::•...,.•:::i:£:.;.:;:::::::::;::;::;
....... .: :::::::::::::::::::::::....::................... ......—:::::::.:::::•`,:.:::::...................�•...................... .................................,`.`.-.......Yf
:w.<:v::::•::::vw:nos:..:: .AJxO •n•:.
..:::::::.::::....:::..::w:n::w:::.
hsnrance.co:<.;> ::::..::.. ......:.... ;- ,:: .....-....;:::::..:::<::;::::::::::;;;;:;,;:;>;:;:. ::<.;<
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........................................................................................................................................................:::::::is;:_::.::•.:�:::::::::::::::::v::::::::::::::::::....h:::.......�w•}:+8'<^i:<:<
i:1Si:<nos.,..::.
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nsnrance:caOW
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Fafimx to seem..overage as regoired under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 3100.00 a day against me. I understood that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verinntion.
I do hereby certify a painnl�
of perjury at the information provided above is&w..and correct
Signature "�� Date //" 9-- f Q
Print name JD vy L(l 1 V".)A J(Z- Phame# �i� --0-*-3 -�l
official we only do not write in this area to be completed by city or town official
city or town: permit/license# ]JO
ng Department
❑chedcBhmm�edlate r requ OLicensing Board
ired mewss OIDce
Department
contact person: phone#;
(Jawed 9195 PJtU
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any conn-..c-,
of hire, express or implied, oral or written. �..
An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver c:
trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant.who has
not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting-
authority. ,
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you
are required to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of levesugallons
600 Washington Street
Boston; Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext 406, 409 or 375
TablalSZ.ib
Fj aza ipdw w Padu4ps!or Ono=W Two-Fiu*Reddaedal Baildlop iftmW with FmsJ Fads
MAXIMUM N MUMUM
Oiling Wan Moor Baas Slab HadvCooiiag
At='(%) U-vaiuer &Vaimj R vduel &Vgiu6j Wall pwimew apdpmm ETi ic=e
Pad�aae R.vabra' Rrvaiud
$701 to 6500 Headua D D&W
QMUSA'
GAO 33 13 19 10 6 N�
R032 30 19 19 10 6 Normal
SOJO 38 13 19 10 6 15 AFUE
T036 35 13 2S WA WA Normal
UOA6 32 19 19 10 6 Normal
1i -0.44 3'a 1+' :3 iWA WA !S AFM
W0M 30 19 19 10 6 MAFUE
x
0,3Z 32 13 23 WA WA Normal
Y0.42 36 19 25 WA WA Normal
Z0.42 31l 13 19 10 6 90 AFUE
AA030 30 !9 19 !0 6 90 AnM
1. ADDRESS OF PROPERTY. 4,� 7 AL izI n2 W4-t4
2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: ` Z�
3. SQUARE FOOTAGE OF ALL GLAZING.
0
4. %GLAZING AREA(#3 DIVIDED BY 92):
S. SELECT PACKAGE(Q—AA-see chart above): _ Q
NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS
ARE AVAILABLE. ASK US FOR THIS INFORMATION.
BUILDING INSPECTOR APPR AL•
YES: NO:
q-forms-i980303a
Footnotes to Table J5.2.1b: .
' Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and
basement windows if located in walls that enclose conditioned space, but excluding opaque doors)to the gross wall
area, expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement.
For example,3 ft of decorative glass may be excluded from a building design with 300 fl of glazing area.
'After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with
the National Fenestration Rating Council (NFR C) test procedure, or taken from Table J1.5.3a. U-values are for
whole units: center-of-glass U-values cannot be used.
' The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full
insulation thickness-over the exterior walls without compression, R-30 insulation may be substituted for R-3 8
insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R values represent the sum of cavity
insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between
the condt'tio ned space and the ventilated portion of the roof.
'Wall R values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include
exterior siding, structural sheathing,and interior drywall.For example, an R 19 requirement could be met E17HER
by R 19 cavity insulation OR R 13 cavity insulation plus R-b insulating sheathing. Wall requirements apply to
wood-fiame or mass(concrete,masonry, log)wall constructions,but do not apply to metal-frame construction.
d The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces,basements,
or garages).Floors over outside air must meet the ceiling requirements.
`The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must
meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned
basements must be included with the other glazing. Basement doors must meet the door U-value requirement
described in Note b.
'The R-value mquirements•are for unheated slabs.Add an additional R-2 for heated slabs.
` If the building utilizes electric resistance Beating use compliance approach 3, 4, or 5. If you plan to install more
than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest
efficiency must meet or exceed the efficiency required by the selected package.
'For Heating Degree Day requirements of the closest city or town see Table J5.2.1 a
NOTES:
a) Glazing areas and U-values are"maxunum acceptable levels. Insulation R values are minimum acceptable levels.
R-value requirements are for insulation only and do not include structural components.
b)Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested
and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value
in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the
glass area of the door with your windows and use the opaque door U-value to determine compliance of the door.
One door may be excluded from this requirement(i.e.,may have a U-value greater than 035).
c) If a ceiling, wall,floor, basement wall,slab-edge,or crawl space wall component includes two or more areas with
different insulation levels, the component complies if the area-weighted average R-value is greater than or equal to
the R-value requirement for that component. Glazing or door components comply if the area-weighted average U-
value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors).
43
MO4211*12a 0/..1AZZIJIW44
OEPARTNENT OF PUBLIC SAFETY
i CONSTRUCTION SUPERVISOR LICENSE
Number Expires:
JOHN W�-,fIi1N.JR%
'rG��.� 46 DOD50H-WAY
E FALNOUTH, HA 925S6
HOME IMPROVEMENT CONTRACTOR "g
441.
Reg istratiot',,,112841
rationog4/29/99
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BUILDING
� NN N N N �� INSPECTOR
^ �� NN N N_�� N ���0
-- _ - ---� - -- ~-
APPLICATION FOR
^ PERMIT TO —.�--- -.--.......~___
' i �^^
� TYPE OF CONSTRUCTION —_-----.��!��.��./���.. .—.-----.--------. �
�
'� � ^v
---.4�..��—x�.e............... 9�r��
-�.TO THE INSPECTOR OF BUILDINGS: '
|
^ - �
The d i 6 hereby appliesfor it according to the following information: .
Location . ......{���.����-----------.--'------------
. ^,
,.vp""=" Use . �^==`= --^-----''�y—^------^^—~---� �
'
Zoning D �84 Fire D��i�� .�.
� Name of ..i�.. .A66mmu --. .��=,:�.-------. �
� /
»�' A66
� Nome of | .+='`. —� emu —..~ ..� .. ~. =r�--------
�
'
/ Nome of Architecto.............................................................Address ..............................................^—.---.-------
Number of Rooms
n6oh
Exlerio, --- Roofing
Floors ----- ��.��A=e.--------.|n^enor --� /�*�
-
Heohng .......... '����r��---P|um6ing ----`=,— .
Fireplace ---.�---..��..�`��=���---.. . .. Approximate Cost --.���6) ...................
Definitive Plan by Planning Board lQ^c�°� . Area --------------
Diagram of Lot and Building with Dimensions Fee _______________
SUBJECT TO APPROVAL OF BOARD OF HEALTH
—
vs~*= .
�� ��4 ^/
^
'
'
'
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
| hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. \
Nome
/
Construction Supervisor's License '_' ............... �
---_ -^ ----'
No Permit for
���Sin�^^ ^.~i ~.^l^^.�
. '
Lot 29, 57 Way '
Location --'--.------- ' -----.. '
.
Centerville
�.--- ......................................... ...................
James K. Smith
Cxwna, ............................................ .................
Frame . ' ' C
Type of Construction" -------�..................
--------------'-----------'' '
Plot -----.---. Lot -----------
` ^
.
. . .
~ June 26, 85
Permit Granted ......................................lg
'
Date of Inspection' ................................l9
` .
. ' �
Dote Completed ....................................... g
'
. .
`
'
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o• �> TOWN OF BARNSTABLE 28087
. Permit No. ---------------------------------
Building Inspector
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Issued to .lanes K. Smith Address
Lot 29, 67 Halvard Wax. Centerville
Wiring Inspector �j� ;r� Inspection date
Plumbing inspectors,. Inspection date
Gas Inspector c• Qtr„ ,` Inspection date P,flr a ! P
X Engineering Department , � � � Inspection date �fi r"'�G.
Board of Health } t t Inspection date s
THIS PERMIT WILL NO BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE. �f7
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Building Inspector
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TOWN OF BARNSTABLE
BUILDING DEPARTMENT
TOWN OFFICE BUILDING
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HYANNIS, MASS. 0260.1
4A
MEMO TO: Town Clerk
FROM: Building DepartmentV�
DATE:
An Occupancy Permit has been issued for the building authorized by
Building Permit # . ...
................................................................................................._............................................_.
issued to .... ... .... �2� l..
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Please release the performance bond.
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Came to see you Please call Special attention
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Message
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Signed
�niversal"48023 LITHO IN U.S.A.
Assessor's map!pnd lot number .....: 7... ..... .. ....... ` . pfTHEto
Sewage Permit number ' S ���o...�K.... C" . ;,�'' _-SEPTIC SYSTEM 6 dUST
INSTALLED IN COMPLIAI
ARNHouse number .s.:r...,.....H �...........................+ WITH TITLE 5 . 63 \e�
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;ENVIRONMENTAL C®DE A OypYAr
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: BUILDING 11SPECT.Ok
APPLICATION. FOR PERMIT TO. .. . ...... .. ..............................
. .. ........ .....
TYPE' OF CONSTRUCTION
... .. ..:.. 1...............t 9 .I :J`
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a ` er it according to the following information: s
Location ... ........✓ .J............ :.. .. ... . . ........16 .. ................. ........ ..................... .........
Proposed Use . .. ... - ... .... ....
Zoning District .......: s--�.�..e :......... .Fire. District .. .�.. . ...........
Name•of Owner .. lC....... + .... Address ..... ... ..............
{ ....................
d G .Address � •••• .
Nameof Build r ............ . . . ..... � ...... ......................_
Nameof•Architec ............................ .......... .Address` ................... .................... .........
Number of Rooms .... ....:.. .....................................................Foundation .... �� ....... .. ... . ... ......
�`. � �� ....:.Roofing / A
Exterior ....... ... - :.Cr4� .... . ..... ..
C�.� .Interior ...'.:......... ... .:. . �..
Floors ................ ......G�G�..l�....d................................... ,
Heating . ........... .. ......�J�: C.. .. .......Plumbing . ......... ......... .... .....
Fireplace ...................... ��- ............................:. Approximate Cost'......A ro �_4. G�
Definitive Plan Approved by Planning•Board� Lf— 19 Area .. ...: .
Diagram of Lot and Building with Dimensions Fee / 4 '... lL.....................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
7
OCCUPANCY PERMITS REQUIRED 'FOR NEW DWELLINGS
I hereby agree to conform to all the Rules. and Regulations of the aTown of Barnstable regarding the above-
construction. '
r Name T..)......
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Construction Supervisor's License
SNiTH, DAMES P.
' 28087 0 Story
No .............. Permit for ..... ...........................
Single Family Dwelling
...` ......: .................................... ...
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` Location ....Lot..29.'......57 Halyard Way......... -
Centerville } ,.. f r :; . w
....................James..K�...Smith......�...................
Owner ................-.................... i h '
47
� Frame a
'TYP a of Construction ....................
........................... ..........................
�. Plot ... . ...... ........... Lot .......................... r e
Permit Granted June 26 .... 19 85 t
Date-of.Inspection . .............................19 -
Date Completed G.. j/�/.•/� .. .....1*9
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LOT 22
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LOT 23
CAS
DFOR AD — PLAN REF. 379/70
Q // FLOOD ZONE.- "Co'
LOT 24 NE °�0 E' g- 4 RES. ZONE.- "RD 1
gVlCE OVERVIEW GP
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LIGHT o LOT 30
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LOT 29 PA.
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LOT 28 ,/-'' `o
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14 � PROJEC T L OCA TON
I ECK cZ 57 HALYARD ROAD
4' -D-=-------------------
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DO _==5�=3-#5 7=_______ r `+ CENTERVILLE,, MA.
/ I 1,28. _ ---
I I - _=__ ASS. MAP 194/66
I o d I y-====_-__-__-- 2 .-- 13.7
313, APPLICANT
JAMES CHURCH
16 1 0_ s-� ce o ODEAN'S EDGE CONSTRUCTION CORP.
— 35. 14 , YANKEE SUR VEY CONSUL TAN TS
I P. O. BOX 265
I I _ L 28. 63 UNIT 1, 408 INDUSTRY ROAD
MARSTONS MILLS, MA. 02648
' 10'I1 .� 9 16 1 PH. (508�428-0055 — FAX(508)420-555J
I Q 9 - 1
4.64
SCALE. I — 30
_ 1 0 DA TE.' 11/24/98
R
REV. [RE-v•
YARP
14ALI JOB NO. 51731 SHEET 1 OF I
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